65 year old female patient with seizure
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 65yr old female resident of lingotum with history of seizures
Chief complaints:-
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The patient was brought with chief complaints of Active involuntary movements 5 days back, history of frothing , mouth deviation to left uprolling eyeball ,no h/o of tongue bite, urinary incontinence, fever, head injury, vomitings, loose stools.
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 11 days back later she developed her first episode of seizure with sudden onset of movements in upper and lower limbs for 5 minutes.
The episode began with headache and dizziness, up-rolling of the eyes followed by loss of consciousness and uncontrolled involuntary movements of the arms and legs, clasping of the hands and deviation of the mouth to one side. She regained consciousness 5-10 minutes later in a confused state, with no memory of the episode. She was brought to the hospital by her son where she was prescribed levetiracetam and she left the day after.
Second episode began in the night time 5 days back (on 2/12/23) and had complaints of headache dragging type pain radiating to neck . This was followed by up-rolling of the eyeballs loss of consciousness and sudden onset of involuntary movements, frothing, deviation of mouth towards left and confusion in postictal period.
No h/o episode of seizure activity after bringing to casualty
no h/o of involuntary defecation
no h/o fever, cough, vomitings, loose stools, pain in abdomen.
PAST HISTORY:-
Similar episode 5 days ago for which she visited a local hospital and got treated .
K/C/O hypertension since 18 years on medication not a known case of DM/HTN/TB/Asthma/CVD/CAD
TREATMENT HISTORY:-
On treatment for hypertension since 18 years
Personal History -
Appetite - Normal
Diet - mixed
Bowel and bladder movement are regular
Sleep adequate
No addictions
Family history - not relevant
General examination
Patient is conscious, coherent and cooperative
Moderately built and nourished
Pallor absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal edema-absent
VITALS:-
Tempurature - 98 F
Pulse- 78 bpm
Blood pressure - 140/90 mmhg
Respiratory rate - 18 cpm
spo2- 99
grbs- 117 mg %
SYSTEMIC EXAMINATION:-
CNS examination
Motor system
Bulk - no wasting of muscle
Tone - normal
Power grading -
Right. Left
Upperlimb +5. +5
Lowerlimb +5. +5
Reflexes -
Biceps - normal
Triceps - normal
Knee jerk present
Ankle jerk present
Sensory system - fine touch , crude touch , pain , temperature sensation are intact
CVS examination
Inspection:-
JVP not seen
Auscultation
S1 S2 heard , no murmurs
RESPIRATORY SYSTEM
chest is bilaterally symmetrical
bilateral airway entry present
trachea - central
no scars
Percussion:-Resonant in nine quadrants
Auscultation- Normal vesicular breath sounds heard
ABDOMINAL EXAMINATION
No local rise of temperature
no tenderness
No organomegaly
Investigation -
Glycated hemoglobin
Lipid profile
Fasting blood sugar
RFT
Hemogram
Ultrasound report
MRI
Provisional diagnosis -
This is a case of 65 year old woman who came with complaint of abnormal movement of hands and limbs lasting for 5 mins preceded by headache suggestive of generalized tonic clinic seizure.
Treatment
Inj. Levipil 500 mg IV
Tab Clinidipine 18 mg OD
Tab Shelcal 500mg OD
Tab Neirobion Forte OD
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